Feedback, Friends, and Outcome in Behavioral Health

My first year in college, my declared major was accounting. What can I say? My family didn’t have much money and my mother–who chose my major for me–thought that the next best thing to wealth was being close to money.

Much to her disappointment I switched from accounting to psychology in my sophomore year. That’s when I first met Dr. Michael Lambert.

It was 1979 and I was enrolled in a required course taught by him on “tests and measures.” He made an impression to be sure. He was young and hip–the only professor I met while earning my Bachelor’s degree who insisted the students call him by his first name. What’s more, his knowledge and passion made what everyone considered the “deadliest” class in the entire curriculum seem positively exciting. (The text, Cronbach’s classic Essentials of Psychological Testing, 3rd Edition, still sits on my bookshelf–one of the few from my undergraduate days). Within a year, I was volunteering as a “research assistant,” reading and then writing up short summaries of research articles.

Even then, Michael was concerned about deterioration in psychotherapy. “There is ample evidence,” he wrote in his 1979 book, The Effects of Psychotherapy (Volume 1), “that psychotherapy can and does cause harm to a portion of those it is intended to help” (p. 6). And where the entire field was focused on methods, he was hot on the trail of what later research would firmly establish as the single largest source of variation in outcome: the therapist. “The therapist’s contribution to effective psychotherapy is evident,” he wrote, “…training and selection on dimensions of…empathy, warmth, and genuineness…is advised, although little research supports the efficacy of current training procedures.” In a passage that would greatly influence the arc of my own career, he continued, “Client perception…of the relationship correlate more highly with outcome that objective judges’ ratings” (Lambert, 1979, p. 32).

Fast forward 32 years. Recently, Michael sent me a pre-publication copy of a mega-analysis of his work on using feedback to improve outcome and reduce deterioration in psychotherapy. Mega-analysis combines original, raw data from multiple studies–in this case 6–to create a large, representative data set of the impact of feedback on outcome. In his accompanying email, he said, “our new study shows what the individual studies have shown.” Routine, ongoing feedback from consumers of behavioral health services not only improves overall outcome but reduces risk of deterioration by nearly two thirds! The article will soon appear in the Journal of Consulting and Clinical Psychology.

Such results were not available when I first began using Lambert’s measure–the OQ 45–in my clinical work. It was late 1996. My colleagues and I had just put the finishing touches on Escape from Babel, our first book together on the “common factors.”

In the envelop was a copy of an article Lynn had written for the journal, Psychotherapy entitled, “Improving Quality in Psychotherapy” in which he argued for the routine measurement of outcome in psychotherapy. He cited three reasons: (1) providing proof of effectiveness to payers; (2) enabling continuous analysis and improvement of service delivery; and (3) giving consumers voice and choice in treatment. (If you’ve never read the article, I highly recommend it–if for no other reason than its historical significance. I’m convinced that the field would be in far better shape now had Lynn’s suggestions been heeded then).

Anyway, I was hooked. I soon had a bootleg copy of the OQ and was using it in combination with Lynn’s Session Rating Scalewith every person I met.

It wasn’t always easy. The measure took time and more than a few of my clients had difficulty reading and comprehending the items on the measure. I was determined however, and so persisted, occasionally extending sessions to 90 minutes so the client and I could read and score the 45-items together.

Almost immediately, routinely measuring and talking about the alliance and outcome had an impact on my work. My average number of sessions began slowly “creeping up” as the number of single-session therapies, missed appointments, and no shows dropped. For the first time in my career, I knew when I was and was not effective. I was also able to determine my overall success rate as a therapist. These early experiences also figured prominently in development of the Outcome Rating Scale and revision of the Session Rating Scale.

More on how the two measures–the OQ 45 and original 10-item SRS–changed from lengthy Likert scales to short, 4-item visual analog measures later. At this point, suffice it to say I’ve been extremely fortunate to have such generous and gifted teachers, mentors, and friends.